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Compendium
September 2019
Volume 40, Issue 8
Peer-Reviewed

Cementation of Zirconia-Based Toothborne Restorations: A Clinical Review

Sami Dogan, DDS, Dr. med. dent.; and Ariel J. Raigrodski, DMD, MS

Abstract: As the demand for esthetics in dentistry has increased over the years, zirconia-based restorations have been successfully used as alternatives to metal-ceramic restorations. A reliable marginal seal is among the factors that are vital to the clinical success of a dental restoration. One advantage of zirconia-based restorations is that the cementation process is generally simpler and more efficient compared to the delivery/cementation of other all-ceramic systems. This article reviews several categories of cement used for the cementation of zirconia restorations: zinc-phosphate cement, glass-ionomer cement (GIC), resin-modified GIC, and composite-resin cement.

Metal-ceramic restorations have been successfully used for fixed restorations for the past 50 years and have served as a benchmark for survival and success of tooth-colored indirect restorations.1 Zirconia-based restorations are alternatives to metal-ceramic restorations because of their strength, biocompatibility, and the increased demand for more highly esthetic restorations.2-6

The clinical success of a dental restoration is determined by its resistance to fracture, marginal fit, esthetic outcome, and survival. Although the marginal fit of zirconia restorations has been shown to be equal to that of metal ceramics,7,8 reliable marginal seal is also important for long-lasting restorations. The most common factors that influence the marginal fit are finish line configuration, cement space dimensions, fabrication process, and cementation. Cementation of zirconia restorations can be a simpler process compared to the delivery/cementation of other all-ceramic systems. Zinc-phosphate cement,9-14 glass-ionomer cement (GIC),15-18 resin-modified GIC,5,19 and composite-resin cement have all been used for cementation of zirconia restorations.13,20-27

Zinc-Phosphate Cement

Loss of abutment tooth vitality, abutment tooth fracture, and secondary caries are predominant biologic complications for crowns.1 Loss of retention has been reported for both metal-ceramic and all-ceramic restorations, and it may occur more frequently in restorations cemented with zinc-phosphate or GIC compared to restorations cemented with composite-resin cements.13 Cement choice may impact the long-term survival rates of restorations if the retention form of the tooth preparation is less than ideal. High rates of loss of retention of single crowns may be related to the total angle of convergence (ie, taper) of the tooth preparation and abutment height rather than cement type.28-30

The most common problems associated with zinc-phosphate cements are ditching at the restoration margin, leakage, and secondary caries.20,31 Although no direct correlation was observed between secondary caries and cement type for zirconia-based crowns that were luted with either composite-resin cement, GIC, zinc-phosphate cement, or temporary cement, the rate of crown loosening after 3 years was 12.5% for zinc-phosphate cement (Phosacem, Ivoclar Vivadent, ivoclarvivadent.com) and 6.6% for self-adhesive modified composite-resin cement (RelyX Unicem, 3M Oral Care, 3m.com).26

In a split-mouth clinical study after 8-year follow-up, estimated survival, which was defined as no loss of retention or no loss of pulp vitality, was 96% (95% with zinc-phosphate cement and 97% with resin-modified GIC) for metal-ceramic and zirconia crowns. The difference between resin-modified GIC and zinc-phosphate cement was shown not to be statistically significant.32 Despite the encouraging retentive capacity of zinc-phosphate-cemented zirconia restorations, after 5 years' follow-up of three-unit fixed partial dentures that were cemented with either composite-resin cement (Panavia F, Kuraray, kuraraydental.com) or zinc-phosphate cement (De Trey® Zinc, Dentsply Sirona, dentsplysirona.com), visible evidence of ditching along the margins was seen in the zinc-phosphate-cemented group.4 Three-unit zirconia bridges (Cad.esthetics system, Denzir AB, denzir.com) were rated satisfactory and only one restoration was recemented after a 5-year observation period. Pitted surfaces and ditching were reported in 30% of bridge retainers that were cemented with phosphate cement.10

Glass-Ionomer Cements and Resin-Modified Glass-Ionomer Cements

GICs are used mainly to cement cast-metal and metal-ceramic restorations with adequate retention and resistance form. Although their ability to bond chemically on tooth surface makes GICs attractive for clinical application, traditional GICs may not be considered as well-suited for high-strength ceramic restorations such as zirconia because of their low strength and solubility in a moist environment33 compared to resin-modified GICs.34 Zirconia-based bridges that were fabricated with zirconia margins and conventionally luted with resin-modified GIC (RelyX Luting, 3M Oral Care) were successful at 5 years of clinical service in terms of marginal adaptation, and no loss of retention or secondary caries was reported.5 Although microleakage scores did not show statistical difference between adhesive-resin cement and GIC for zirconia crowns,35 adhesive methods may provide better retention, improve marginal adaptation, and prevent microleakage.36,37

Posterior three-unit zirconia-based bridges (Cercon®, DeguDent GmbH, Dentsply Sirona) veneered with pressable glass-ceramic (Cercon Ceram Express) showed loss of retention on one distal abutment of a mandibular bridge replacing the first molar after 3 years of clinical service. These were cemented with Ketac Cem Aplicap (3M Oral Care) after air-particle abrasion (50 μm aluminum oxide, 500 HPa pressure).16 In general, short-term studies of less than 5 years' follow-up showed good survival rates for either zirconia-based or metal-ceramic bridges cemented with GICs. Bridges manufactured with computer-aided design/computer-aided manufacturing (CAD/CAM) zirconia showed survival rate of 100% for the frameworks 3 years after cementation with GIC (Ketac Cem, 3M Oral Care). After 3 years, the marginal integrity at the abutment teeth was ranked excellent in 91% of the restorations with small numbers of discoloration on the margin without evidence of caries.38

Composite-Resin Cements

Adhesive cementation has been clinically proven to be a suitable procedure for the permanent seating of indirect restorations. However, adhesive cementation procedure typically is more technique-sensitive than conventional luting procedures and requires a strict clinical protocol. Zirconia cementation with different composite-resin cements is promoted in different studies if the retention and resistance forms are less than ideal. Although a zirconia-based restoration cemented with a dual-cure, self-adhesive resin cement (RelyX Unicem) showed no debonding after 3-year follow-up39 and 5-year follow-up,27 clinical evaluation of single crowns after up to 7 years of service cemented with either zinc polycarboxylate (Poly-F®, Dentsply Sirona), composite resin (Panavia F 2.0, Kuraray), or resin-modified GIC (Fuji Plus®, GC America, gcamerica.com) showed that debonding could be related to taper of the preparation or use of short abutments instead of cement type.28,40 Self-adhesive composite-resin cements are an attractive option for zirconia-based restorations without requiring any pretreatment, such as etching, priming, air-particle abrasion, or use of a bonding agent, prior to cementation. However, discoloration with no evidence of secondary caries and no pitting along the margins was observed in three-unit veneered zirconia bridges cemented with a composite-resin cement (RelyX Unicem) after 3 years.41 Cold sensitivity or post-cementation sensitivity after cementation can be an issue with these cements because of their acidic self-adhesive properties. There are reports, however, showing no difference between self-adhesive and total-etch composite-resin cements.42,43

Crowns and bridges manufactured with four zirconia systems (Cercon, Dentsply Sirona; ZirkonZahn®, zirkonzahn.com; Lava, 3M Oral Care; Katana, Kuraray) and cemented using dual-cured composite-resin cement (Panavia F 2.0) showed predictable high survival rates on teeth with no debonding or secondary caries after 4 years of clinical service.44 Zirconia crowns bonded with dual-polymerizing, self-adhesive composite-resin cement (RelyX Unicem) showed 80% success and 89% survival rates after 2 to 6 years of service. Loss of cementation was found to be only 4%.45 Zirconia-based anterior maxillary crowns with customized copings cemented with dual-polymerizing, self-adhesive composite-resin cement (RelyX Unicem) performed well with no loss of cementation and no secondary caries after 5 years of service with a survival rate of 100%.27

To enhance bonding between composite-resin cement and zirconia, air-particle abrasion of the intaglio surface is advocated. Tribochemical silica coating with an air-abrasion device (CoJet System, 3M Oral Care) may be effective treatment for zirconia intaglio surfaces to increase the bond.46 Surface pretreatments such as hydrofluoric acid etching or silanization may not improve the bonding strength of zirconia because of the material's quasi-chemical inertness with limited adhesive luting potential.47-50 Combined surface treatments using airborne particle abrasion and specific adhesives with a hydrophobic phosphate monomer currently are clinically accepted techniques for bonding to zirconia ceramics.51-57 Moderate-pressure airborne-particle abrasion in combination with phosphate monomer-containing (10-methacryloyloxydecyl dihydrogen phosphate [MDP]) primer or luting resin is recommended to provide a long-lasting durable bond to zirconia to achieve a decreased decementation rate.57 Application of a tribochemical silica coating in combination with an MDP-containing bonding/silane coupling agent mixture may increase the shear bond strength between zirconium-oxide ceramic and phosphate-modified resin cement (eg, Panavia F).

The tribochemical silica coating process was also tested with zirconia silanization, which resulted in an increased bond strength. Silane/phosphate bonding agent for cementing zirconia restorative material does not necessarily require another mechano-chemical treatment before application of the silane/phosphate bonding agent; however, stable bond strength was achieved with tribochemical silica coating of zirconia and with phosphate monomer and silane. This bonding mechanism is similar to bonding with feldspathic porcelain with silane/MDP bonding agent.58 In a study with a 5-year follow-up in which pretreatment of the restorations included airborne particle abrasion with aluminum oxide (110 µm, 200 kPa) and luting with dual-polymerizing, self-adhesive composite-resin cement (RelyX Unicem), none of the zirconia bridges required recementation and no secondary caries was found.59 A similar clinical study with three-unit zirconia-based bridges in the premolar and molar regions luted with RelyX Unicem without any surface treatment showed no loss of retention after 5 years of clinical service.60 In addition, zirconia-based surveyed crowns (ZirkonZahn) for partial removable dental prostheses bonded with dual-polymerizing, self-adhesive composite-resin cement (RelyX Unicem) showed no loss of retention in a 4-year clinical retrospective study.59 Finally, zirconia-based bridges cemented with a self-adhesive resin-based luting system (RelyX Unicem) demonstrated a similar survival rate to metal-ceramic bridges after 4 years of clinical service with no retention loss or decementation.39,61,62

To clean the abutment tooth before adhesive cementation, mechanical cleaning with pumice paste and slurry is advocated instead of using hydrogen peroxide, ethylenediaminetetraacetic acid (EDTA), or sodium carbonate solution. Air-particle abrasion of the abutment tooth is also an accepted procedure. Some clinicians have considered the use of phosphoric acid for cleaning the intaglio surface immediately after try-in before definitive cementation. Because of zirconia's strong affinity toward the phosphate group, phosphoric acid interacts with zirconia surfaces to form zirconium phosphate. However, zirconium phosphate will be inert to the adhesive cement's phosphate group.63 This can cause lower bond strength between the zirconia-based intaglio surface and the composite-resin cement.64

Summary

Zirconia-based restorations are considered an acceptable option for restoring anterior and posterior dentitions. Indications for conventional cementation should be critically reviewed, because greater loss of retention occurred in restorations cemented with zinc-phosphate cement or GICs compared to those cemented with composite-resin cements. Self-etching, self-adhesive resin cements were shown in numerous clinical studies to be clinically reliable with better mechanical strength compared to zinc-phosphate cements and GICs. Moreover, self-adhesive resin cements are also clinically appealing to the dentist because the need for pretreatment, such as etching, priming, or using a bonding agent, is eliminated, providing a less technique-sensitive, simple, fast, and predictable cementation protocol. Further well-designed studies with large patient groups and long follow-up times are needed to obtain long-term clinical information on cementation of zirconia-based restorations.

Disclosure

Dr. Raigrodski periodically receives speaker honoraria from 3M Oral Care, though he did not receive any specifically for this article.

About the Authors

Sami Dogan, DDS, Dr. med. dent.
Associate Professor, Department of Restorative Dentistry, University of Washington, Seattle, Washington

Ariel J. Raigrodski, DMD, MS
Affiliate Professor, Department of Restorative Dentistry, University of Washington, Seattle, Washington; Diplomate, American Board of Prosthodontics; Private Practice, Lynnwood, Washington

References

1. Goodacre CJ, Bernal G, Rungcharassaeng K, Kan JY. Clinical complications in fixed prosthodontics. J Prosthet Dent. 2003;90(1):31-41.

2. Creugers NH, Käyser AF, van't Hof MA. A meta-analysis of durability data on conventional fixed bridges. Community Dent Oral Epidemiol. 1994;22(6):448-452.

3. Tan K, Pjetursson  BE, Lang NP, Chan ES. A systematic review of the survival and complication rates of fixed partial dentures (FPDs) after an observation period of at least 5 years. Clin Oral Implants Res. 2004;15
(6):654-666.

4. Scurria MS, Bader JD, Shugars DA. Meta-analysis of fixed partial denture survival: prostheses and abutments. J Prosthet Dent. 1998;79(4):459-464.

5. Raigrodski AJ, Yu A, Chiche GJ, et al. Clinical efficacy of veneered zirconium dioxide-based posterior partial fixed dental prostheses: five-year results. J Prosthet Dent. 2012;108(4):214-222.

6. Raigrodski AJ, Hillstead MB, Meng GK, Chung KH. Survival and complications of zirconia-based fixed dental prostheses: a systematic review. J Prosthet Dent. 2012;107(3):170-177.

7. Biscaro L, Bonfiglioli R, Soattin M, Vigolo P. An in vivo evaluation of fit of zirconium-oxide based ceramic single crowns, generated with two CAD/CAM systems, in comparison to metal ceramic single crowns. J Prosthodont. 2013;22(1):36-41.

8. Song TJ, Kwon TK, Yang JH, et al. Marginal fit of anterior 3-unit fixed partial zirconia restorations using different CAD/CAM systems. J Adv Prosthodont. 2013;5(3):219-225.

9. Vult von Steyern P, Carlson P, Nilner K. All-ceramic fixed partial dentures designed according to the DC-Zirkon technique. A 2-year clinical study. J Oral Rehabil. 2005;32(3):180-187.

10. Molin MK, Karlsson SL. Five-year clinical prospective evaluation of zirconia-based Denzir 3-unit FPDs. Int J Prosthodont. 2008;21(3):223-227.

11. Larsson C, Vult von Steyern P, Sunzel B, Nilner K. All-ceramic two- to five-unit implant-supported reconstructions. A randomized, prospective clinical trial. Swed Dent J. 2006;30(2):45-53.

12. Bornemann G. Prospective clinical trial with conventionally luted zirconia-based fixed partial dentures-18-month results. J Dent Res. 2003;82(spec iss B):Abstract 117.

13. Tinschert J, Schulze KA, Natt G, et al. Clinical behavior of zirconia-based fixed partial dentures made of DC-Zirkon: 3-year results. Int J Prosthodont. 2008;21(3):217-222.

14. Ortorp A, Kihl ML, Carlsson GE. A 3-year retrospective and clinical follow-up study of zirconia single crowns performed in a private practice. J Dent. 2009;37(9):731-736.

15. Cehreli MC, Kökat AM, Akça K. CAD/CAM zirconia vs. slip-cast glass-infiltrated alumina/zirconia all-ceramic crowns: 2-year results of a randomized controlled clinical trial. J Appl Oral Sci. 2009;17(1):49-55.

16. Beuer F, Edelhoff D, Gernet W, Sorensen JA. Three-year clinical prospective evaluation of zirconia-based posterior fixed dental prostheses (FDPs). Clin Oral Investig. 2009;13(4):445-451.

17. Schmitter M, Mussotter K, Rammelsberg P, et al. Clinical performance of extended zirconia frameworks for fixed dental prostheses: two-year results. J Oral Rehabil. 2009;36(8):610-615.

18. Pospiech P, Rountree P, Nothdurft F. Clinical evaluation of zirconia-based all-ceramic posterior bridges: two-year results. J Dent Res. 2003;82(spec iss B):Abstract 114.

19. Edelhoff D, Florian B, Florian W, Johnen C. HIP zirconia fixed partial dentures-clinical results after 3 years of clinical service. Quintessence Int. 2008;39(6):459-471.

20. Molin MK, Karlsson SL. Five-year clinical prospective evaluation of zirconia-based Denzir 3-unit FPDs. Int J Prosthodont. 2008;21(3):223-227.

21. Sailer I, Fehér A, Filser F, et al. Prospective clinical study of zirconia posterior fixed partial dentures: 3-year follow-up. Quintessence Int. 2006;37(9):685-693.

22. Sailer I, Fehér A, Filser F, et al. Five-year clinical results of zirconia frameworks for posterior fixed partial dentures. Int J Prosthodont. 2007;
20(4):383-388.

23. Glauser R, Sailer I, Wohlwend A, et al. Experimental zirconia abutments for implant-supported single-tooth restorations in esthetically demanding regions: 4-year results of a prospective clinical study. Int J Prosthodont. 2004;17(3):285-290.

24. Crisp RJ, Cowan AJ, Lamb J, et al. A clinical evaluation of all-ceramic bridges placed in UK general dental practices: first-year results. Br Dent J. 2008;205(9):477-482.

25. Ohlmann B, Rammelsberg P, Schmitter M, et al. All-ceramic inlay-retained fixed partial dentures: preliminary results from a clinical study. J Dent. 2008;36(9):692-696.

26. Ortorp A, Kihl ML, Carlsson GE. A 5-year retrospective study of survival of zirconia single crowns fitted in a private clinical setting. J Dent. 2012;40(6):527-530.

27. Dogan S, Raigrodski AJ, Zhang H, Mancl LA. Prospective cohort clinical study assessing the 5-year survival and success of anterior maxillary zirconia-based crowns with customized zirconia copings. J Prosthet Dent. 2017;117(2):226-232.

28. Shahin R, Kern M. Effect of air-abrasion on the retention of zirconia ceramic crowns luted with different cements before and after artificial aging. Dent Mater. 2010;26(9):922-928.

29. Nejatidanesh F, Savabi O, Shahtoosi M. Retention of implant-supported zirconium oxide ceramic restorations using different luting agents. Clin Oral Implants Res. 2013;24(suppl A100):20-24.

30. Nejatidanesh F, Savabi O, Jabbari E. Effect of surface treatment on the retention of implant-supported zirconia restorations over short abutments. J Prosthet Dent. 2014;112(1):38-44.

31. Albert FE, El-Mowafy OM. Marginal adaptation and microleakage of Procera AllCeram crowns with four cements. Int J Prosthodont. 2004;17(5):529-535.

32. Jokstad A. A split-mouth randomized clinical trial of single crowns retained with resin-modified glass-ionomer and zinc phosphate luting cements. Int J Prosthodont. 2004;17(4):411-416.

33. Davidson CL. Advances in glass-ionomer cements. J Appl Oral Sci. 2006;14 suppl:3-9.

34. Knobloch LA, Kerby RE, McMillen K, Clelland N. Solubility and sorption of resin-based luting cements. Oper Dent. 2000;25(5):434-440.

35. Sener I, Turker B, Valandro LF, Ozcan M. Marginal gap, cement thickness, and microleakage of 2 zirconia crown systems luted with glass ionomer and MDP-based cements. Gen Dent. 2014;62(2):67-70.

36. Ernst CP, Cohnen U, Stender E, Willershausen B. In vitro retentive strength of zirconium oxide ceramic crowns using different luting agents. J Prosthet Dent. 2005;93(6):551-558.

37. Palacios RP, Johnson GH, Phillips KM, Raigrodski AJ. Retention of zirconium oxide ceramic crowns with three types of cement. J Prosthet Dent. 2006;96(2):104-114.

38. Schmitt J, Holst S, Wichmann M, et al. Zirconia posterior fixed partial dentures: a prospective clinical 3-year follow-up. Int J Prosthodont. 2009;22(6):597-603.

39. Gherlone E, Mandelli F, Capparè P, et al. A 3 years retrospective study of survival for zirconia-based single crowns fabricated from intraoral digital impressions. J Dent. 2014;42(9):1151-1155.

40. Nejatidanesh F, Moradpoor H, Savabi O. Clinical outcomes of zirconia-based implant- and tooth-supported single crowns. Clin Oral Investig. 2016;20(1):169-178.

41. Pelaez J, Cogolludo PG, Serrano B, et al. A four-year prospective clinical evaluation of zirconia and metal-ceramic posterior fixed dental prostheses. Int J Prosthodont. 2012:25(5):451-458.

42. Powers JM. Self-adhesive resin cements: characteristics, properties, and manipulation. Advanced Esthetics & Interdisciplinary Dentistry. 2008;2(1):34-36.

43. Robles AA, Yaman P, Dennison JB, et al. All-ceramic restorations luted with a self-etching adhesive: two-year report. J Dent Res. 2008;87
(spec iss A):Abstract 671.

44. Sagirkaya E, Arikan S, Sadik B, et al. A randomized, prospective, open-ended clinical trial of zirconia fixed partial dentures on teeth and implants: interim results. Int J Prosthodont. 2012;25(3):221-231.

45. Näpänkangas R, Pihlaja J, Raustia A. Outcome of zirconia single crowns made by predoctoral dental students: a clinical retrospective study after 2 to 6 years of clinical service. J Prosthet Dent. 2015;113
(4):289-294.

46. Atsu SS, Kilicarslan MA, Kucukesmen HC, Aka PS. Effect of zirconium-oxide ceramic surface treatments on the bond strength to adhesive resin. J Prosthet Dent. 2006;95(6):430-436.

47. Thompson JY, Stoner BR, Piascik JR, Smith R. Adhesion/cementation to zirconia and other non-silicate ceramics: where are we now? Dent Mater. 2011;27(1):71-82.

48. Blatz MB. Adhesive cementation of high-strength ceramics. J Esthet Restor Dent. 2007;19(5):238-239.

49. Dérand P, Dérand T. Bond strength of luting cements to zirconium oxide ceramics. Int J Prosthodont. 2000;13(2):131-135.

50. Borges GA, Sophr AM, de Goes MF, et al. Effect of etching and airborne particle abrasion on the microstructure of different dental ceramics. J Prosthet Dent. 2003;89(5):479-488.

51. Chen L, Suh BI, Brown D, Chen X. Bonding of primed zirconia ceramics: evidence of chemical bonding and improved bond strengths. Am J Dent. 2012;25(2):103-108.

52. Koizumi H, Nakayama D, Komine F, et al. Bonding of resin-based luting cements to zirconia with and without the use of ceramic priming agents. J Adhes Dent. 2012;14(4):385-392.

53. Kern M, Wegner SM. Bonding to zirconia ceramic: adhesion methods and their durability. Dent Mater. 1998;14(1):64-71.

54. Blatz MB, Sadan A, Kern M. Resin-ceramic bonding: a review of the literature. J Prosthet Dent. 2003;89(3):268-274.

55. Wegner SM, Kern M. Long-term resin bond strength to zirconia ceramic. J Adhes Dent. 2000;2(2):139-147.

56. Lehmann F, Kern M. Durability of resin bonding to zirconia ceramic using different primers. J Adhes Dent. 2009;11(6):479-483.

57. Kern M. Bonding to oxide ceramics-laboratory testing versus clinical outcome. Dent Mater. 2015;31(1):8-14.

58. Tanaka R, Fujishima A, Shibata Y, et al. Cooperation of phosphate monomer and silica modification on zirconia. J Dent Res. 2008;87(7):
666-670.

59. Pihlaja J, Näpänkangas R, Raustia A. Outcome of zirconia partial fixed dental prostheses made by predoctoral dental students: a clinical retrospective study after 3 to 7 years of clinical service. J Prosthet Dent. 2016;116(1):40-46.

60. Sorrentino R, De Simone G, Tetè S, et al. Five-year prospective clinical study of posterior three-unit zirconia-based fixed dental prostheses. Clin Oral Investig. 2012;16(3):977-985.

61. Crisp RJ, Cowan AJ, Lamb J, et al. A clinical evaluation of all-ceramic bridges placed in patients attending UK general dental practices: three-year results. Dent Mater. 2012;28(3):229-236.

62. Burke FJ, Crisp RJ, Cowan AJ, et al. Five-year clinical evaluation of zirconia-based bridges in patients in UK general dental practices. J Dent. 2013;41(11):992-999.

63. Kweon HK, Hakansson K. Selective zirconium dioxide-based enrichment of phosphorylated peptides for mass spectrometric analysis. Anal Chem. 2006;78(6):1743-1749.

64. Yang B, Lange-Jansen HC, Scharnberg M, et al. Influence of saliva contamination on zirconia ceramic bonding. Dent Mater. 2008;24(4):
508-513.

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